Male factor infertility is present in about 40% of infertility cases.
Initial testing for male factor infertility requires a sperm analysis. Normal male ejaculate is 2-5mL in volume. Each milliliter contains 15 to 20 million sperm, 50% of them are moving and about 30% of them are normal in shape, using World Health Organization criteria or 4%, using Kruger strict criteria for morphology. Fertility treatment for male factor is extremely successful even with very few sperm, ejaculated or surgically retrieved.
Consultation with a reproductive endocrinologist, in addition to a urologist, is extremely helpful because he or he or she is able to evaluate female factors and also can suggest simple measures e.g freezing a sperm sample that can preserve your potential for having children in the future. Many times the indication or type of intervention in the male need to be changed due to female factors as blocked tubes or low egg reserve.
In general, supplements, medical treatment and most varicocele repairs yield lower success and longer waiting time to conception than assisted reproduction.
Mild Male Factor Infertility:
In men with 10 million motile sperm or more, fertility can be enhanced with sperm preparation and insemination of prepared sperm into the uterus.
Moderate to severe Male Factor:
In men with less than 10 million motile sperm IVF yields better pregnancy rates. If complex abnormalities exist in the number, motility and shape, intracytoplasmic sperm injection (one sperm introduced into the egg) results in higher fertilization rates.
Azospermia: No sperm appear in the ejaculate due to obstruction in male ducts conducting sperm to outside or due to markedly reduced sperm production:
Obstructive Azospermia; Obstruction could be genetic e.g congenital bilateral absence of vas deferens or acquired e.g after vasectomy. Treatment options include retrieval of sperm from the testes and use them for IVF or surgical treatment of obstruction. Surgical sperm retrieval and IVF appears to be more successful. If you decide to undergo surgery to relief obstruction, it is important to retrieve some sperm and freeze them in case surgery is not successful.
Non-obstructive azospermia; Decreased sperm production could also be genetic e.g Kleinfelter syndrome, Kallmann syndrome, abnormalities in Y chromosome or acquired e.g. following chemotherapy.
Diligent search for sperm in semen samples is first performed. If none found, sperm can be directly retrieved from the testes using an outpatient surgery (TESE).
Men with severe male factor may carry some genetic risks that should be investigated before fertility treatment. These sometimes include abnormal chromosomes e.g Klinefelter syndrome, abnormalities in the Y chromosome, abnormalities in cystic fibrosis genes (bilateral absence of the vas). We thoroughly investigate these factors during the initial workup.
Erectile dysfunction: men with difficulty in maintaining erection or with ejaculation can also be helped with non invasive methods obtaining sperm that can be frozen and used fresh to achieve pregnancy.
Retrograde ejaculation: In some men e.g men diagnosed with diabetes, sperm may flow backwards into the urinary bladder. Sperm can be retrieved from a urine sample or directly from the testes.
This is an example of obstructive azospermia. Men with prior vasectomy and want to father children can undergo vasectomy reversal.
Alternative options to vasectomy reversal:
- Use sperm frozen prior to vasectomy if any.
- Harvest sperm from the testes and use those for IVF with their partners while leaving the vasectomy in place for long term contraception.
The choice of treatment should include evaluation of female factors. Also even if vasectomy reversal is contemplated, sperm should be obtained during the reversal and frozen in case reversal is not successful.
These are dilated veins around the testes.
Although some varicoceles are associated with abnormal sperm parameters, there is no strong evidence that varicocele repair increases the odds for pregnancy in female partners.